<form id="form_medicine_usage" name="form_medicine_usage">

    <div><span id="status_message" style="font-style: italic; color: red;"></span></div>
    <input type="hidden" id="hid_id" name="hid_id" />
    
    <table cellspacing="0" cellpadding="0">
        <tr>
            <td colspan="2" class="field" style="text-transform: uppercase">{translate}Usage{/translate}</td>
        </tr>
        
        <tr>
            <td class="label">{translate}Usage name{/translate} (*)</td>
            <td class="field">
               <input type="text" id="usage_title" name='usage_title' size="25"  /> 
            </td>
            <td>&nbsp;</td>
        </tr>
        
        <tr>
            <td class="label">{translate}Usage{/translate}</td>
            <td class="field">
               <input type="text" id="usage_unit" name='usage_unit' size="25"  /> 
            </td>
            <td class="field">
               <input type="text" id="usage_num" name='usage_num' size="5" onkeyup="javascript: this.value = this.value.replace(/[^0-9]/g, '');" /> 
            </td>
        </tr>
        
         <tr>
            <td class="label">{translate}Dosage{/translate}</td>
            <td class="field">
               <input type="text" id="dosage" name='dosage' size="5" onkeyup="javascript: this.value = this.value.replace(/[^0-9]/g, '');" /> &nbsp;{translate}times/day{/translate}
            </td>
            <td class="label">{translate}Time{/translate}</td>
            <td class="field">
               <input type="text" id="time" name='time' size="5" onkeyup="javascript: this.value = this.value.replace(/[^0-9]/g, '');" /> &nbsp;{translate}day(s){/translate}
            </td>
            
            <td>&nbsp;</td>
        </tr>
        
        <tr>
            <td class="label">{translate}Quantity{/translate}</td>
            <td class="field">
               <input type="text" id="quantity_title" name='quantity_title' size="25"  /> 
            </td>            
            <td class="field">
               <input type="text" id="quantity_num" name='quantity_num' size="5" onkeyup="javascript: this.value = this.value.replace(/[^0-9]/g, '');" /> 
            </td>
        </tr>
        
        <tr>    
        	<td colspan="4">&nbsp;</td>        
            <td style="float: right;">
            	<input id="button_save" type="button" value="{translate}Save{/translate}" onclick="javascript:saveMedicineUsage();" >
            	<input id="button_cancel" type="button" value="{translate}Cancel{/translate}" onclick="javascript:cancelMedicineUsage();" >
            	<div id="barLoading" style="display: none;">
                        <img src="{$base_uri}images/ajax-loader.gif"/>
                </div>
            </td>                                
        </tr>
        
    </table>

</form>
